Copyright C Blackwell Munksgaard 2002

Periodontology 2000, Vol. 29, 2002, 710

Printed in Denmark. All rights reserved

PERIODONTOLOGY 2000
ISSN 0906-6713

Global epidemiology of
periodontal diseases:
an overview
J M. A & T E. R

This volume aims to provide a comprehensive

evaluation of the distribution of various types of
periodontal diseases from each of the worlds five
major geographic regions. Epidemiology is the
study of the health and disease in populations, as
compared to individuals (20). Study of the distribution of human periodontal diseases and their
risk factors on a global scale offers a unique investigational model that can provide power and generalization to observations on the periodontium
made initially among more limited populations. In
assessing causation between periodontal diseases
and their suspected etiologic risk factors, it is useful to demonstrate consistency of the relationships
in multiple, representative population samples.
When diverse study approaches in various populations by different investigators produce similar conclusions on the distribution of periodontal diseases
and/or their associations with putative risk factors,
then one can be more confident that real phenomenon and/or causal relationships exist (29). Indeed,
population-based studies provide external validity
to observations obtained from more discrete subject groups, and enable generalization of the conclusions (14). Alternatively, differences in periodontal disease patterns among various population
groups can be exploited to uncover previously unidentified risk factors that may not be expressed in
all populations.
Available population-based periodontal disease
data originate from studies encompassing a wide
range of objectives, designs and measurement criteria (18). The lack of standardized study design,
definition of periodontal disease status, methods for
disease detection and measurement, and criteria for
subject selection markedly limit interpretation and

analysis of available population-based periodontal

disease data from around the world. However, several broad trends on the nature of human periodontal diseases are apparent across the wide range
of population-based data.
Population studies confirm the close relationship
between dental plaque and gingivitis that was initially described by Le et al. (21) in nonpopulationbased studies. Throughout the globe, dental plaque
growth and inflammation of gingival tissue are
ubiquitous and strongly linked, irrespective of age,
gender or racial/ethnic identification. More than
82% of U.S. adolescents have overt gingivitis and
signs of gingival bleeding (2), with similar or higher
prevalences of gingivitis being reported for children
and adolescents in other parts of the world (4, 12,
13, 15, 25). A high prevalence of gingivitis is also
found in adults, with more than half of the U.S. adult
population estimated to exhibit gingival bleeding (1,
6, 24), and other populations showing even higher
levels of gingival inflammation (25).
While gingivitis parallels the level of oral hygiene
in a population, it is by itself a poor predictor of subsequent periodontitis disease activity (5, 16, 19).
However, young subjects with overt gingival inflammation more frequently exhibit periodontal
attachment loss than adolescents without gingival
inflammation (2). Furthermore, gingivitis always appears to precede the development of periodontitis,
as no data from around the world indicate that the
onset of periodontitis occurs without gingival inflammation.
It is clear from global epidemiology data that a less
pronounced relationship appears to exist between
dental plaque and severe periodontitis. Severe forms
of human periodontitis frequently affect only a sub-

Albandar & Rams

set of population groups globally, even though

plaque-induced gingivitis and slight to moderate
forms of periodontitis are widespread within the
same population groups. A relatively small subset of
populations in the United States (6), Central and
South America (15), Europe (27), Africa (7), and Asia/
Oceania (10) exhibit severe forms of periodontal
attachment loss with deep periodontal pocket formation. The relatively lower occurrence of severe
periodontitis in many of the studied populations
may in part be attributed to the lack of standardized
study design and disease measurement criteria used,
and the effects of marked tooth loss in persons with
severe periodontitis, which would serve to reduce
the prevalence of severe periodontitis as edentulous
conditions occur. However, it is likely that additional, unidentified risk factors beyond dental
plaque and gingivitis alone are important in the
onset and pathogenesis of severe forms of periodontitis.
In this regard, the relative contribution of various
proposed risk factors in severe periodontitis remain
to be fully delineated. Most studies fail to assess
aspects of study subjects (i.e. genetic, biochemical,
microbiologic and/or immunologic markers) beyond basic demographic characteristics. There is a
relative paucity of analytic studies which account
for a wide range of potential independent risk factors for severe periodontitis. For example, several
gene polymorphisms have been investigated relative to their associations with periodontitis, and
some of these have been shown to be related to
increased risk for aggressive disease (5). The most
significant gene aberrations studied so far are those
thought to be associated with altered host immune
response to infection, including interleukin-1 (IL1) gene, vitamin D receptor gene, and fMLP receptor gene.
However, the effects of various genetic risk factors
are not exclusive, and these effects explain only a
part of the variance in the occurrence of aggressive
periodontitis, and to a lesser degree, chronic periodontitis. Studies show that there is a significant interaction between genetic factors and other environmental and demographic factors, including a possible modifying effect of smoking, and a variability in
the occurrence of certain genotypes in different
race-ethnicity groups (5). Hence, more analytic
studies encompassing a wider range of potential risk
variables are needed to better understand the role of
these and other factors in the increased susceptibility to destructive periodontal diseases.
Another problem with many population-based

periodontal studies has been the reliance upon

measurement of probing depth as an indicator of
disease status. At a population level, probing pocket
depth measurements are of limited value for the appraisal of the extent and severity of periodontal diseases for the following reasons:
O An increase in the probing depth at a given tooth
site may or may not be associated with attachment loss at that site.
O The probing pocket depth at a given site is a
changeable measure. A reduction of the probing
depth with aging due to gingival recession is frequently observed (22), and does not necessarily
indicate improved periodontal status.
O Probing depth does not provide an accurate
measure of periodontal tissue destruction accumulated over a persons lifetime as reliably as
assessments of periodontal attachment level.
Significant disparities appear to exist in the level of
periodontitis among young, adult and senior populations in the world. Subjects of African ethnicity
seem to have the highest prevalence of periodontitis, followed by Hispanics and Asians. Disparities in periodontal status appear to occur largely between the poor and the rich. Populations with
a lower socioeconomic level cannot afford dental
treatment. These populations often lack healthy attitudes and behaviors for oral health, as well as for
systemic health. In addition, periodontal disease
susceptibility is further aggravated by the apparent
occurrence in these populations of certain biological and microbiological risk factors that further increase their predisposition to periodontal diseases
(3, 5).
Epidemiologic data can form the basis for selection and implementation of strategies to prevent and
treat periodontal diseases. Three broad strategies
have been advanced (26, 28):
O Population strategy: uses a community-wide approach in which health education and other
favorable life practices are introduced in the community, and unfavorable behaviors are attempted
to be changed.
O Secondary prevention strategy: includes detecting
and treating individuals with destructive periodontal diseases. Basically, health education is an
integral part of this strategy, although it is more
customized to the needs of the individual patient.
Dental health education approaches to improve
the oral hygiene of the individual patient, al-

Global epidemiology of periodontal diseases

though successful in the short-term, have been

shown to be relatively ineffective in making sustained changes in oral hygiene behaviors (27).
This may be partly due to the failure to incorporate social contextual factors and other factors,
such as loss of function and esthetics, and the
general health impact of periodontal diseases, in
these programs.
O Identification of high risk groups for periodontitis:
the early detection of active disease and identification of subjects and groups who are more likely
to develop destructive periodontal diseases in the
future are important elements of dental care systems planning.
The selection of the most appropriate of the above
strategies for a given population group is dependent
upon the disease distribution and nature of risk factors pertinent to periodontal diseases in that particular population.
In the future, adoption of better oral hygiene
should have a notable impact on the occurrence of
periodontal disease. Awareness of the occurrence of
disease, the infectious nature of these diseases, and
the available means of risk assessment and disease
prevention (11, 23), may be achieved through a
better interaction between oral health providers and
community decision makers, and changes in the
educational programs in the population to promote
healthy attitudes. The advent of fluoride and its effect in markedly reducing the incidence of dental
caries has resulted in a notable increase in tooth retention worldwide (9), and a higher number of retained teeth may be accompanied by increases in the
prevalence and severity of periodontal attachment
loss in the population (17). Finally, as more people
are living longer, with retention of their teeth, a
greater prevalence of destructive periodontal disease
may be expected to occur (8).
Although behavioral changes, including better oral
hygiene habits, smoking cessation programs, and
other behavioral and promotional programs may potentially improve periodontal health, the overall
benefits may be offset and even surpassed by the
increases in the prevalence and severity of periodontal attachment loss which will accompany the
anticipated increase in tooth retention and longer
life expectancy. In the coming years on a global
basis, it may be foreseen that a decrease in prevalence and severity of periodontal attachment loss in
populations younger than 50 years is likely together
with an increase in periodontal disease in older age
groups.

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